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' APPLICATION FOR SANITATION PERMIT Permit No. ........ ___ p p (Comlete in Duplicate) ..Date Issued _---a--�---------.5 Adlication is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. Thisapplicationis made in compliance with County Ordinance No. 549. JOB ADDRESS AND LOCATI N- �� ------- 10 ~ = 107 ,,�� -------------------------------------------- Phone �_ Owner's Name-------- V-11---------- 41- ----------- + Address ------------•---------------------------------------------------------------------•-- ---------------- 1 Contractor's Name-------- "........------------------------------------------------------------------------------------------------- Phone----------------------------------- Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel [j Other [r} Number of living units: '�___ Number of bedrooms _I-___ Number of baths I_____ Lot size ---A-----1. -_` "�.__j __________ Water Supply: Public system ❑ Community system ❑ Private X, Depth to Water Table -------- ft. Character of soil to a depth of 3 feet: Sand "Gravel E] Sandy Loam Clay Loam ❑ Clay El Adobe [Hardpan El Previous Application Made: Yes E] No New Construction: Yes No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: \ (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Materi I- . Septic Tank: Distance from nearest well, ---DistanceLfrorrr#our��lation___� �_. - ------------------ Capacity --_-_-_- - No. of compartments---------�-----------Size_ ,ll__ X__`�_______Liquid depth_____ p y___ Ca acit --- Disposal Field: Distance from nearest well__ _ Distance from foundation__ O-Dista nearest lot line! Number of lines_____,_____ _ _________ ___Length of each line--__ __ __ Tr__ - dtF�drench____ � pp Total length--------- 1- -------------- Type of filter materia{___�_�___hrf�._Depth of filter material____ __ _-_._ Seepage Pit: Distance to nearest well----------------------Distance from foundation------------.-------Distance to nearest lot line------------ j -_. " ❑ . Number of pits----------------------Lining material---------------------,-Size: Diameter-----------------------Depth-----------------------------__-- I Cesspool• Distance from nearest well________________Distance from foundation-__________-- ---.Lining material-------------------------------------- El Size: Diameter-------------------------------------Depth-------------------------------------- ------_Liquid Capacity----------------------------gals. Privy: Disfance from nearest well--------------------------------------------------Distance from nearest building__________________-______-____-________- [] Distance to nearest lot line----------------------------------------------------- ---- Remodeling and/or repairing (describe)------------------- - ----- a -------------------------------------------------------- ----------------------------------------------------------------------------------------------------------,-- , ------------------------------------------------ -------- ------------------------------------------------- --•-------------------------------------------------------------------------------------------------------------- I hereby certify that I have -gpared this application and that the work will be done in accordance with San Joaquin County ordinances, St to laws, and r -Td regulations of the San Joaquin Local Health District. [Signed}__ .� ____________________________(Owner and/or Contractor) By:----- --------------------------------------------------------------------------------•-------------------------------(Title)--------------------------------------------------------------- (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE. ONLY AAPPLICATIONACCEPTED BY------------------------------ --- -------------------------------------------- DATE-------- ---- --' y ------ f REVIEWEDBY------------------------------------------------------------------------------------------------------------------------------- DATE----------------------------------------- ------- BUILDINGPERMIT ISSUED------------------------------------------------------------------------------------------------------ DATE------------------------------------------------------------- Alterationsand/or recommendations:--------------------------------------------------------------------------------------------------------------------------------------------------------------- --------------------------------------------------------------------- ----------------------------------------------------------------- ------ --------------------------------------------------------------------------------------------------------------------- FINALINSPECTION BY---------------------------------------------------------------•- Date-------------------------------------------------------------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES-9-2M 8-51 Revised W-2100 F